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Nurse Practitioner, House Calls Program (MI MSO)

Company: Oak Street Health
Location: Detroit
Posted on: July 8, 2024

Job Description:

Title: Nurse Practitioner, In-Home Care (Michigan MSO)Role DescriptionThe House Calls Nurse Practitioner delivers high-touch, high-quality, home-based primary care to the highest risk patients. Our NP's lead a cohesive team of Oakies to provide wrap-around, comprehensive, in-home support and care. NPs, along with their Medical Assistant/Scribes, make 4-6 visits daily in a defined territory and collaborate continuously with other team members for care coordination, social services, and behavioral health care. Provider teams enjoy easy access to clinical support from peers and medical directors, tailored clinical education for in-home providers, and dedicated non-clinical time for panel management and patient discussions, using best in class population health data. This is a traveling position that provides in-home primary care to medically complex seniors.Program OverviewThe House Calls Program (known as @HOME) delivers high-quality primary care to Medicare patients in their home. The @HOME program takes a team-based approach to providing outstanding patient care. Our Care Teams - consisting of a Provider, Medical Assistant/Scribe (CIS/MA), Behavioral Health Specialist (BHS) and Mobile Operations Coordinator (MOC) - build individual relationships across a small panel of patients, seen monthly. The Care Team is responsible for delivering excellent, high-touch primary care, and coordinating the care of patients.Core ResponsibilitiesProvide longitudinal care to high frailty patients according to defined pathways within the patientient's homeDevelop care plans and individualize goals of care with patient and familiesOptimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challengesCollaborate with home health, specialists, social workers, hospitals, SNFs, and specialistsStructure and prioritize scheduling based on clinical complexity for both new and routine patientsRecognize, diagnose, and manage both acute and chronic medical conditionsFacilitate and conduct goals of care and advance care planning discussions with patients and familiesAssess and evaluate family / caregiver needs and limitationsTeach patients, caregivers, and others about their health conditionsEmbrace Oak Street Health care and risk model, including clinic workflows that support panel health and accurate codingAccurate and timely documentation of patient encounters in Oak Streetas electronic medical recordChampion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident ReportingOther duties, as assignedWhat are we looking forGenuine passion for primary care and reaching vulnerable patientsStrong clinical skills focused on older adults with complex disease statesComfort navigating visits in patient homesDemonstrated ability to collaborate effectively in a team settingWillingness to learn and be accountable for visit documentation and workflowsExcellent communication, follow-up, teamwork, and problem-solving skillsDesire to be a part of a fast-paced, innovative, quality-driven organizationRequired QualificationsHave an active, non-probationary state medical license, including US work authorization, if applicable1+ years APN experience, preferably with a Medicare populationExperience in home-based care (as RN or APN) preferredFlexibility to travel throughout service areaElectronic Medical Record experienceComputer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not requiredWhat does being Oaky look like?Radiating positive energyAssuming good intentionsCreating an unmatched patient experienceDriving clinical excellenceTaking ownership and delivering resultsBeing relentlessly determinedWhy Oak Street Health? Oak Street Health is on a mission to Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patients' communities and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.Oak Street Health Benefits:Mission-focused career impacting change and measurably improving health outcomes for Medicare patientsPaid vacation, sick time, and investment/retirement 401K match optionsHealth insurance, vision, and dental benefitsOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.Learn more at Jobble

Keywords: Oak Street Health, Detroit , Nurse Practitioner, House Calls Program (MI MSO), Healthcare , Detroit, Michigan

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